As a psychiatrist, I don't feel competent to prescribe testosterone and when the issue comes up, i refer my patients back to their PCP or to an Endocrinologist- there have been recent reports of****ociations between TT and both increased CV events and prostate cancer- medscape has a nice summary http://www.medscape.com/features/slideshow/testosterone-deficiency?src=wnl_edit_specol&uac=12332SK#7 if you can't open the link the main take homes from a 2010 Endocrine Society Guideline are as follows_ only****ess men with symptoms- 2 morning samples both unequivocally low are necessary for dx of T deficiency, reassess level 3-6 months after initiating therapy- aim for mid-normal range level, avoid TT if palpable prostate (i am not competent to determine this!!!), PSA >4 OR >3 If considered high risk for prostate ca, HCT > 50, severe LUTS, and finally use with extreme caution in men with hx of heart disease.

It's a lot harder to get people to lose weight than to treat with testosterone. Testosterone in proper dosage has few undesirable effects and many desirable ones like improved libido, increased muscle strength, delayed aging symptoms, reduced body fat, and increased muscle mass.

Opiates cause low T. But so does obesity. As such, I try and work on wt control before Rxing Testosterone supplement, even in the face of a low serum Testosterone level. Wt control promotes over all good health, all good "side effects" of taking off some poundage, whereas Testosterone has many undesirable side effects.

I think that JMurbach is probably correct, but I wonder how much of it is "hard-wired" whether by genotype or culture. I think it would be very very very difficult for all but a tiny percent of men to change this view. I'd be interested in any references that discuss this at length. Is it specific to certain cultures? Was it true 100 years ago when Playboy didn't exist?

As far as testing for T, do you test in men and women? Are there norms for women? I know that T controls libido in both sexes. Women often complain of decreased libido in recovery. Is it the bup? Is it being "not high" and dealing with reality? Clearly very complex stuff that needs more than a cursory examination and is unlikely to respond to our usual desire for a "pill" to "cure" it.

JMurbach- I find that i keep thinking about your post- i think you are suggesting that "relational-sexuality" is a learned behavior that comes more naturally to women but is accessible to men and can help ameliorate the bup induced sexual dysfunction? This stirkes me as genius and a real break through- thanks for sharing- I am thinking of bringing this up with my men's only buprenorphine group- i will let you all know how it goes.

I have a somewhat different take on at least some of what we see with sexual dysfunction. Males in adolescence have lots of testosterone, and early sexuality is fantasy-based, not relationally-based. Whether with pornography or a girl, much of the arousal relates to an 'internal fantasy' experience; many males NEVER progress to what I call 'relational-sexuality' which is how most females experience sexual desire (note: I realize that this model is a generalization and not true in every case). This fantasy-drive is strongly diminished by SSRI's (a mainstay in Sexual Offender treatment, where a major part of the problem is fantasy-driven sexuality) as well as opioids.

A patient of mine (late 30's-early 40s to be intentionally vague) complained of marked loss of sexual performance on sertraline and suboxone. We discussed the nature of sexual arousal, noting that a male might look at his wife bending over to load the dishwasher, admire the curve of her rear end, and have sexual thoughts. OTOH his wife might see him come into the kitchen, take over doing the dishes, and tell her to sit down and relax while he cleans up. This romantic/relational interaction is more likely to lead to arousal for her. I suggested that he tend to more relational awareness of her, spending time talking, cuddling, kissing, and such. He returned and was VERY pleased to see that his arousal response was quite different. His words: "Doc, what you're telling me is that we have to become more like women!"

This is certainly just a subset of what we see going on, but I believe that relational issues (past and present) are at the heart of what most addicts (and plenty of other people) are struggling with. Erectile dysfunction or diminished desire is one element of this. In a culture that seems hell-bent on moving MORE towards fantasy-driven behavior in BOTH males AND females, my view is quite counter-cultural. I have this silly notion that sexuality is part of a committed marital relationship. Relational issues are central...and of course, that is often mirrored in the relational issues with me, the psychotherapist (and prescriber of the magical fruit of the bup tree). Anyway, enough for now...

In some, yohimbe can cause some anxiety. For those folks, they won't be able to tolerate it and won't take more than one dose. Otherwise, it's pretty good. I like to ask the pt to bring their spouse/partner to the visit with me after I first start it so I can also ask the spouse/partner what he or she thinks about the Yocon.

Don't neglect other possible causes of erectile dysfunction. Is it limited to one sexual partner but not others? Was it a problem in the past, prior to opiates, suggesting a sexual arousal disorder? Does the patient sometimes awaken in the morning with an erection, suggesting psychological issues are possible? Has he been checked for diabetes? Is there a vascular disorder - sometimes one of the early signs of athersclerotic disease is erectile dysfunction. Mike